Medicare Wellness and sick EM - same day - different providers

wegrant630

Expert
Local Chapter Officer
Messages
290
Location
Bryant, AR
Best answers
0
We have providers that bill for both services in the same day, using the 25 modifier to show that the services are separately identifiable. Medicare always pays for one or the other, but never both. An appeal has to be done in order to get payment. So, can a patient receive a sick visit by the MD and have the mid-level bill for the Medicare Wellness on the same day?
 
Messages
811
Best answers
0
We have providers that bill for both services in the same day, using the 25 modifier to show that the services are separately identifiable. Medicare always pays for one or the other, but never both. An appeal has to be done in order to get payment. So, can a patient receive a sick visit by the MD and have the mid-level bill for the Medicare Wellness on the same day?

Out of curiosity, why isn't either the MD or the NPP just completing both services? Medicare states to bill to the highest level possible, so one is likely to get lumped into another. Medicare also states that only one E/M service may be provider to a Medicare patient per day. The exception is when there are extenuating circumstances that cause two separate visits, for example, a patient is seen for a cough in the morning and returns in the afternoon for leg pain.

pg 46 might help...
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads//clm104c12.pdf
 
Top